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Self-harm The short-term physical and psychological management and secondary prevention of self- harm in primary and secondary care Issued: July 2004 NICE clinical guideline 16 www.nice.org.uk/cg16 Copyright © NICE 2004 Self-harm Contents NICE clinical guideline 16 Key priorities for implementation .................................................................................................. 4 Respect, understanding and choice ..................................................................................... 4 Staff training ......................................................................................................................... 4 Activated charcoal ................................................................................................................ 4 Triage ................................................................................................................................... 4 Treatment ............................................................................................................................. 5 Assessment of needs ........................................................................................................... 5 Assessment of risk ............................................................................................................... 5 Psychological, psychosocial and pharmacological interventions .......................................... 5 1 Guidance .............................................................................................................................. 7 1.1 Issues for all services and healthcare professionals .................................................. 7 1.2 The management of self-harm in primary care......................................................... 12 1.3 The assessment and initial management of self-harm by ambulance services ........ 14 1.4 The treatment and management of self-harm in emergency departments ............... 17 1.5 Medical and surgical management of self-harm ....................................................... 19 1.6 Support and advice for people who repeatedly self-harm ........................................ 25 1.7 Psychosocial assessment ........................................................................................ 26 1.8 Referral, admission and discharge following self-harm ............................................ 27 1.9 Special issues for children and young people (under 16 years) ............................... 28 1.10 Special issues for older people (older than 65 years) .............................................. 30 1.11 Psychological, psychosocial and pharmacological interventions ............................. 31 2 Notes on the scope of the guidance ................................................................................... 33 3 Implementation in the NHS ................................................................................................. 34 3.1 In general ................................................................................................................. 34 3.2 Audit ......................................................................................................................... 34 4 Research recommendations ............................................................................................... 35 5 Other versions of this guideline .......................................................................................... 37 Full guideline ...................................................................................................................... 37 Information for the public .................................................................................................... 37 Quick reference guide ........................................................................................................ 37 6 Review date ........................................................................................................................ 38 Appendix A: Grading scheme .................................................................................................... 39 Appendix B: The Guideline Development Group ....................................................................... 41 Copyright © NICE 2004.
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Last modified July 2004 Page 2 of 52 Self-harm NICE clinical guideline 16 Appendix C: The Guideline Review Panel ................................................................................. 43 Appendix D: Technical detail on the criteria for audit ................................................................. 44 About this guideline .................................................................................................................... 50 Changes since publication ......................................................................................................... 52 Copyright © NICE 2004.
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Last modified July 2004 Page 3 of 52 Self-harm NICE clinical guideline 16 Key priorities for implementation Respect, understanding and choice People who have self-harmed should be treated with the same care, respect and privacy as any patient.

In addition, healthcare professionals should take full account of the likely distress associated with self-harm.
Staff training Clinical and non-clinical staff who have contact with people who self-harm in any setting should be provided with appropriate training to equip them to understand and care for people who have self-harmed.

Activated charcoal Ambulance and emergency department services whose staff may be involved in the care of people who have self-harmed by poisoning should ensure that activated charcoal is immediately available to staff at all times.
Triage All people who have self-harmed should be offered a preliminary psychosocial assessment at triage (or at the initial assessment in primary or community settings) following an act of self-harm.

Assessment should determine a person's mental capacity, their willingness to remain for further (psychosocial) assessment, their level of distress and the possible presence of mental illness.
Consideration should be given to introducing the Australian Mental Health Triage Scale, as it is a comprehensive assessment scale that provides an effective process for rating clinical urgency so that patients are seen in a timely manner.

If a person who has self-harmed has to wait for treatment, he or she should be offered an environment that is safe, supportive and minimises any distress.

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Last modified July 2004 Page 4 of 52 Self-harm NICE clinical guideline 16 may be a separate, quiet room with supervision and regular contact with a named member of staff to ensure safety.

Treatment People who have self-harmed should be offered treatment for the physical consequences of self-harm, regardless of their willingness to accept psychosocial assessment or psychiatric treatment.
Adequate anaesthesia and/or analgesia should be offered to people who have self-injured throughout the process of suturing or other painful treatments.

Staff should provide full information about the treatment options, and make all efforts necessary to ensure that someone who has self-harmed can give, and has the opportunity to give, meaningful and informed consent before any and each procedure (for example, taking the person to hospital by ambulance) or treatment is initiated.
Assessment of needs All people who have self-harmed should be offered an assessment of needs, which should be comprehensive and include evaluation of the social, psychological and motivational factors specific to the act of self-harm, current suicidal intent and hopelessness, as well as a full mental health and social needs assessment.
Assessment of risk All people who have self-harmed should be assessed for risk: this assessment should include identification of the main clinical and demographic features known to be associated with risk of further self-harm and/or suicide, and identification of the key psychological characteristics associated with risk, in particular depression, hopelessness and continuing suicidal intent.
Psychological, psychosocial and pharmacological interventions Following psychosocial assessment for people who have self-harmed, the decision about referral for further treatment and help should be based upon a comprehensive psychiatric, Copyright © NICE 2004.

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Last modified July 2004 Page 5 of 52 Self-harm NICE clinical guideline 16 psychological and social assessment, including an assessment of risk, and should not be determined solely on the basis of having self-harmed.
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Last modified July 2004 Page 6 of 52 Self-harm NICE clinical guideline 16 1 Guidance There have been changes in recommendations 1.7.3.3, 1.7.3.4, 1.9.1.13, 1.11.1.4 and 1.11.1.5.

See Changes since publication for details.

This guideline makes recommendations for the physical, psychological and social assessment and treatment of people in primary and secondary care in the first 48 hours after having self- harmed.
For the purpose of this guideline, the term self-harm is defined as 'self-poisoning or injury, irrespective of the apparent purpose of the act'.

Self-harm is an expression of personal distress, not an illness, and there are many varied reasons for a person to harm him or herself.
In the first part, the guideline makes recommendations that apply across the whole health community, wherever people who self-harm present for help, including good practice points to improve the integration of the different services involved.

In the second part of the guideline, the recommendations directly address the care offered to people who self-harm presenting in primary care, in the community, or in secondary care.
Throughout the guideline, the need to treat people who self-harm with compassion and understanding is emphasised.

The guideline is relevant to all people aged 8 years of age and older who have self-harmed.

Where it refers to children and young people, this applies to all people who are between 8 and 16 years of age inclusive.

However, it should be borne in mind that local services vary the upper age limit depending upon whether a young person is in full-time education or not.
1.1 Issues for all services and healthcare professionals 1.1.1 Users' experience of services The experience of care for people who self-harm is often unacceptable.

All healthcare practitioners involved in the assessment and treatment of people who self-harm should ensure that the care they offer addresses this as a priority.

Respect, understanding and choice 1.1.1.1 People who have self-harmed should be treated with the same care, respect and privacy as any patient.
In addition, healthcare professionals should take full account of the likely distress associated with self-harm.

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Last modified July 2004 Page 7 of 52 Self-harm NICE clinical guideline 16 1.1.1.2 Providing treatment and care for people who have self-harmed is emotionally demanding and requires a high level of communication skills and support.
All staff undertaking this work should have regular clinical supervision in which the emotional impact upon staff members can be discussed and understood.

1.1.1.3 Wherever possible, people who have self-harmed should be offered the choice of male or female staff for both assessment and treatment.

When this is not possible, the reasons should be explained to the service user and written in their notes.
1.1.1.4 When assessing people who self-harm, healthcare professionals should ask service users to explain their feelings and understanding of their own self-harm in their own words.

1.1.1.5 When caring for people who repeatedly self-harm, healthcare professionals should be aware that the individual's reasons for self-harming may be different on each occasion and therefore each episode needs to be treated in its own right.
1.1.1.6 Healthcare professionals should involve people who self-harm in all discussions and decision-making about their treatment and subsequent care.

To do this, staff should provide people who self-harm with full information about the different treatment options available.

When relatives or carers are present 1.1.1.7 People who self-harm should be allowed, if they wish, to be accompanied by a family member, friend or advocate during assessment and treatment.
However, for the initial psychosocial assessment, the interview should take place with the service user alone to maintain confidentiality and to allow discussion about issues that may relate to the relationship between the service user and carers.

1.1.1.8 Healthcare professionals should provide emotional support and help if necessary to the relatives/carers of people who have self-harmed, as they may also be experiencing high levels of distress and anxiety.

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Last modified July 2004 Page 8 of 52 Self-harm NICE clinical guideline 16 Specific issues regarding treatment and care 1.1.1.9 People who have self-harmed should be offered treatment for the physical consequences of self-harm, regardless of their willingness to accept psychosocial assessment or psychiatric treatment.
1.1.1.10 Adequate anaesthesia and/or analgesia should be offered to people who have self- injured throughout the process of suturing or other painful treatments.

1.1.1.11 When physical treatment of self-injury is likely to evoke distressing memories of any previous sexual abuse, for example when repairing harm to the genital area, sedation should be offered in advance.

1.1.2 Staff training and service planning Self-harm is poorly understood by many NHS staff.
All staff that come into contact with people who self-harm need dedicated training to improve both their understanding of self-harm and the treatment and care they provide.

Effective collaboration of all local health organisations will be essential to develop properly integrated services.
Staff training 1.1.2.1 Clinical and non-clinical staff who have contact with people who self-harm in any setting should be provided with appropriate training to equip them to understand and care for people who have self-harmed.

1.1.2.2 People who self-harm should be involved in the planning and delivery of training for staff.
1.1.2.3 Emergency departments should make training available in the assessment of mental health needs and the preliminary management of mental health problems, for all healthcare staff working in that environment.

1.1.2.4 Mental health services and emergency department services should jointly develop regular training programmes in the psychosocial assessment and early management of self-harm, to be undertaken by all healthcare professionals who may assess or treat people who have self-harmed.
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Last modified July 2004 Page 9 of 52 Self-harm NICE clinical guideline 16 Planning of services 1.1.2.5 Strategic Health Authorities, Primary Care Trusts (PCTs), acute trusts and mental health trusts should ensure that people who self-harm are involved in the commissioning, planning and evaluation of services for people who self-harm.
1.1.2.6 Emergency departments, PCTs and local mental health services, in conjunction with local service users and carers wherever possible, should jointly plan the configuration and delivery of integrated physical and mental healthcare services within emergency departments for people who self-harm.
1.1.2.7 Emergency departments catering for children and young people under 16 years of age, PCTs and local children's mental health services, in conjunction with local carers and service users, should jointly plan the configuration and delivery of integrated physical and mental healthcare services within emergency departments for children and young people who self-harm.
1.1.2.8 In jointly planning an integrated emergency department service for people who self- harm, service managers should consider integrating mental health professionals into the emergency department, both to improve the psychosocial assessment and initial treatment for people who self-harm, and to provide routine and regular training to non-mental-health professionals working in the emergency department.
1.1.2.9 Emergency department and local mental health services should jointly plan effective liaison psychiatric services available 24 hours a day.

1.1.3 Consent to care Issues of consent, mental capacity and mental ill health in the assessment and treatment of people who self-harm should be understood and addressed by all healthcare professionals involved in the care of this group of people.
1.1.3.1 All healthcare professionals who have contact, in the emergency situation, with people who have self-harmed should be adequately trained to assess mental capacity and to make decisions about when treatment and care can be given without consent.

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Last modified July 2004 Page 10 of 52 Self-harm NICE clinical guideline 16 1.1.3.2 Primary healthcare practitioners, ambulance staff, triage nurses and emergency department medical staff should assess and document mental capacity as part of the routine assessment of people who have self-harmed.
Within the bounds of patient confidentiality, and subject to the patient's consent, staff should attempt to obtain relevant information from relatives, friends, carers and other key people, to inform the assessment.

1.1.3.3 In the assessment and treatment of people who have self-harmed, mental capacity should be assumed unless there is evidence to the contrary.
1.1.3.4 Staff should provide full information about the treatment options, and make all efforts necessary to ensure that someone who has self-harmed can give, and has the opportunity to give, meaningful and informed consent before any and each procedure (for example, taking the person to hospital by ambulance) or treatment is initiated.

1.1.3.5 If a person is assessed as being mentally incapable, staff have a responsibility, under common law, to act in that person's best interests.
If necessary, this can include taking the person to hospital, and detaining them to allow assessment and treatment against the person's stated wishes.

1.1.3.6 Staff should take into account that a person's capacity to make informed decisions may change over time.

Whether it has been possible to obtain consent or not, attempts should be made to explain each new treatment or procedure and obtain consent before it is initiated.
1.1.3.7 Staff working with people who self-harm should understand when and how the Mental Health Act can be used to treat the physical consequences of self-harm.

1.1.3.8 Staff working with people who self-harm should have easy access to legal advice about issues relating to capacity and consent at all times.
1.1.4 Activated charcoal For the majority of drugs taken in overdose, taking activated charcoal as early as possible, preferably within 1 hour of ingestion, can prevent or reduce absorption of the drug.

Activated charcoal should be immediately available for rapid and appropriate use.

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Last modified July 2004 Page 11 of 52 Self-harm NICE clinical guideline 16 1.1.4.1 Ambulance and emergency department services whose staff may be involved in the care of people who have self-harmed by poisoning should ensure that activated charcoal is immediately available to staff at all times.
1.1.4.2 All healthcare professionals who are able to offer activated charcoal to people who have self-poisoned should ensure that they know how and when this should be administered.

This should include: knowing for which poisons activated charcoal should and should not be used the potential dangers and contraindications of giving activated charcoal the need to encourage and support service users when offering activated charcoal.
1.2 The management of self-harm in primary care Primary care has an important role in the assessment and treatment of people who self-harm.

Careful attention to prescribing drugs to people at risk of self-harm, and their relatives, could also help in prevention.

In remote areas, access to TOXBASE (the national database of the National Poisons Information Service [NPIS]) may be necessary.
1.2.1.1 When an individual presents in primary care following an episode of self-harm, healthcare professionals should urgently establish the likely physical risk, and the person's emotional and mental state, in an atmosphere of respect and understanding.
1.2.1.2 All people who have self-harmed should be assessed for risk, which should include identification of the main clinical and demographic features and psychological characteristics known to be associated with risk, in particular depression, hopelessness and continuing suicidal intent.

The outcome of the assessment should be communicated to other staff and organisations who become involved in the care of the service user.
1.2.1.3 In the assessment and management of self-injury in primary care, healthcare professionals should refer service users for urgent treatment in an emergency Copyright © NICE 2004.

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Last modified July 2004 Page 12 of 52 Self-harm NICE clinical guideline 16 department, if assessment suggests there is a significant risk to the individual who has self-injured.
1.2.1.4 In most circumstances, people who have self-poisoned and present to primary care should be urgently referred to the nearest emergency department, because the nature and quantity of the ingested substances may not be clearly known to the person who has self-poisoned, making accurate risk assessment difficult.
1.2.1.5 If there is any doubt about the seriousness of an episode of self-harm, the general practitioner should discuss the case with the nearest emergency department consultant, as management in secondary care may be necessary.
1.2.1.6 Consideration should be given to the service user's welfare during transportation to any referral organisation and, if necessary, this should be supervised by an appropriate person where there is a risk of further self-harm or reluctance to attend other care centres, or the service user is very distressed.
1.2.1.7 In remote areas at considerable distance from an emergency department or where access is likely to be delayed, consideration should be given to initiating assessment and treatment of self-harm in the primary care setting, following discussion with the nearest emergency department consultant.

This should include taking samples to test for paracetamol and other drugs, as indicated in TOXBASE.
When urgent referral to an emergency department is not necessary 1.2.1.8 If urgent referral to an emergency department is not considered necessary for people who have self-injured in primary care, a risk and needs assessment should be undertaken to assess the case for urgent referral to secondary mental health services.
1.2.1.9 Assessment of the service user's needs should be comprehensive and should include evaluation of the social, psychological and motivational factors specific to the act of self-harm, current intent and hopelessness, as well as a full mental health and social needs assessment.

1.2.1.10 Following assessment and treatment of self-harm in primary care, the outcome of the risk and needs assessment, and full details of the treatment provided, should be Copyright © NICE 2004.

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Last modified July 2004 Page 13 of 52 Self-harm NICE clinical guideline 16 forwarded to the appropriate secondary mental health team at the earliest opportunity.

1.2.1.11 Healthcare professionals who may have to assess and/or treat people who have self- harmed should ensure that they are properly trained and competent to undertake assessment and treatment as necessary.
Service users at risk of self-poisoning in primary care 1.2.1.12 In service users who are considered at risk of self-poisoning, healthcare professionals should prescribe, whenever possible, those drugs which, whilst effective for their intended use, are least dangerous in overdose, and should consider prescribing fewer tablets at any one time.

1.2.1.13 Consideration should be given to preventing or reducing the prescription of co- proxamol, especially for people who are at risk of self-poisoning.
1.2.1.14 As medication intended for relatives is often used in self-poisoning, healthcare professionals should prescribe, whenever possible, those drugs which, whilst effective for their intended use, are least dangerous in overdose when prescribing medication to relatives who live with a person who is considered at risk of self- poisoning.

They should also consider prescribing fewer tablets at any one time.

Care must be taken, however, to preserve confidentiality appropriately.
1.3 The assessment and initial management of self-harm by ambulance services Ambulance staff have an increasingly important role in the assessment and early treatment of self-harm, a role that needs to be well supported through effective collaboration with other professional groups.

1.3.1.1 When ambulance staff attend a person who has self-harmed, they should urgently establish the likely physical risk, and the person's emotional and mental state, in an atmosphere of respect and understanding.
1.3.1.2 Ambulance staff should be trained in the assessment and early management of self- harm.

Training should particularly address the different methods of self-harm and the Copyright © NICE 2004.

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Last modified July 2004 Page 14 of 52 Self-harm NICE clinical guideline 16 appropriate treatments, the likely effects if untreated, and issues of consent and mental capacity, as these apply both to adults, and to children and young people.
1.3.1.3 In cases where, following an act of self-injury, the service user does not require emergency treatment in the emergency department, ambulance staff should consider, having taken full account of the service user's preferences, taking the service user to an alternative appropriate service, such as a specialist mental health service.

The decision to do so should be taken jointly between the ambulance staff, the service user and the receiving service.
1.3.1.4 Ambulance Trusts, the emergency department and Mental Health Trusts should work in partnership to develop locally agreed protocols for ambulance staff to consider alternative care pathways to emergency departments for people who have self- harmed, where this is appropriate and does not increase the risks to the service user.
1.3.1.5 In cases of self-poisoning, ambulance staff should obtain all substances and/or medications found at the scene of an emergency call, whether thought to be involved in the overdose or not, and pass these to staff upon arrival at the emergency department.
1.3.1.6 Unless the service user's clinical condition requires urgent treatment that should not be delayed, ambulance staff should record relevant information about the service user's home environment, social and family support network, and history leading to self-harm, as well as the service user's initial emotional state and level of distress.

This information should be passed to emergency department staff.
1.3.1.7 When transporting people who have self-harmed to an emergency department, wherever possible, ambulance staff should take into account the service user's preferences when more than one emergency department facility exists within a reasonable distance, unless doing so significantly increases the risk to the service user, or when one department has specialised in the treatment of people who have self-harmed.
1.3.1.8 When a person who has self-poisoned presents to the ambulance service within 1 hour of ingestion and is fully conscious and able to protect his or her own airway, Copyright © NICE 2004.

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Last modified July 2004 Page 15 of 52 Self-harm NICE clinical guideline 16 ambulance staff should consider offering activated charcoal at the earliest opportunity.
Activated charcoal should be offered only when the substance(s) ingested are likely to be adsorbed by activated charcoal and when the person is considered to be at risk of significant harm.

1.3.1.9 Activated charcoal may also be considered between 1 and 2 hours after ingestion as there is some evidence that activated charcoal may still be effective in reducing absorption, especially if the ingested substance delays gastric emptying, such as tricyclic antidepressants.
Activated charcoal should be offered only when the substance(s) ingested are likely to be adsorbed by activated charcoal and when the person is considered to be at risk of significant harm.

1.3.1.10 In the emergency treatment of opioid overdose when using intravenous naloxone, ambulance staff should adhere to the guidelines established by the Joint Royal Colleges Ambulance Liaison Committee.
Particular attention should be given to the possible need for repeated doses of naloxone and frequent monitoring of vital signs, because the effects of naloxone are short-lived in comparison with the effects of most opioids and service users frequently relapse once the effect of naloxone has worn off.

All people who have overdosed with opioids should be conveyed to hospital, even if the initial response to naloxone has been good.
1.3.1.11 The ambulance services should ensure that there is rapid access to TOXBASE and the NPIS so that their crew can gain additional information on substances and/or drugs ingested in cases of self-poisoning in order to assist in decisions regarding urgent treatment and the transfer of patients to the most appropriate facilities.
1.3.1.12 When people who have self-harmed are considering refusing further treatment, ambulance staff should assess mental capacity and provide information about the potential consequences of not receiving treatment when attempting to gain valid consent.

When consent is withheld, the guidance on consent and capacity in this guideline should be followed.
1.3.1.13 PCTs, in conjunction with acute and mental health trusts, should consider the level of support needed for the delivery of an adequate pre-hospital care system for self- harm.

Specific consideration should be given to the provision of telephone advice to Copyright © NICE 2004.

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Last modified July 2004 Page 16 of 52 Self-harm NICE clinical guideline 16 ambulance staff from crisis resolution teams, approved social workers and Section 12 approved doctors, regarding the assessment of mental capacity and the possible use of the Mental Health Act in the urgent assessment of people who have self-harmed.
1.3.1.14 Ambulance Trusts should regularly update ambulance staff about any change in local arrangements for services available for the emergency treatment of people who have self-harmed.

1.3.1.15 Ambulance Trusts should routinely audit incidents of overdose, both to ensure that interventions are being used consistently and effectively, and to monitor adverse incidents.
1.4 The treatment and management of self-harm in emergency departments The emergency department provides the main services for people who self-harm.

Emergency department staff should assess risk and emotional, mental and physical state quickly, and try to encourage people to stay to organise psychosocial assessment.
1.4.1 Triage 1.4.1.1 When an individual presents in the emergency department following an episode of self-harm, emergency department staff responsible for triage should urgently establish the likely physical risk, and the person's emotional and mental state, in an atmosphere of respect and understanding.
1.4.1.2 Emergency department staff responsible for triage should take account of the underlying emotional distress, which may not be outwardly exhibited, as well as the severity of injury when making decisions about priority for treatment.

1.4.1.3 Consideration should be given to introducing the Australian Mental Health Triage Scale, as it is a comprehensive assessment scale that provides an effective process for rating clinical urgency so that patients are seen in a timely manner.
1.4.1.4 Triage nurses working in emergency departments should be trained in the use of mental health triage systems.

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Last modified July 2004 Page 17 of 52 Self-harm NICE clinical guideline 16 1.4.1.5 All people who have self-harmed should be offered a preliminary psychosocial assessment at triage (or at the initial assessment in primary or community settings) following an act of self-harm.
Assessment should determine a person's mental capacity, their willingness to remain for further (psychosocial) assessment, their level of distress and the possible presence of mental illness.

1.4.2 People waiting for physical treatments 1.4.2.1 A psychosocial assessment should not be delayed until after medical treatment is complete, unless life-saving medical treatment is needed, or the patient is unconscious or otherwise incapable of being assessed.
1.4.2.2 People who have self-harmed should be provided with clear and understandable information about the care process, both verbally and as written material in a language they understand.

1.4.2.3 If a person who has self-harmed has to wait for treatment, he or she should be offered an environment that is safe, supportive and minimises any distress.

For many patients, this may be a separate, quiet room with supervision and regular contact with a named member of staff to ensure safety.
1.4.3 People who wish to leave before assessment and/or treatment 1.4.3.1 For a person who has self-harmed and presents to services, but wishes to leave before psychosocial assessment has been undertaken, assessment of mental capacity and the presence of mental illness should be undertaken before the person leaves the service.

This assessment should be clearly recorded in his or her notes.
The assessment should be passed on to the person's GP and to the relevant mental health services as soon as possible to enable rapid follow-up.

1.4.3.2 People who have self-harmed and present to services and wish to leave before psychosocial assessment has been undertaken, and in whom diminished capacity and/or the presence of a significant mental illness is established, should be referred for urgent mental health assessment.
Appropriate measures should also be taken to prevent the person leaving the service.

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Last modified July 2004 Page 18 of 52 Self-harm NICE clinical guideline 16 1.5 Medical and surgical management of self-harm Self-poisoning can be treated by reducing absorption, increasing elimination and/or countering the biological effects of the poison, depending upon the nature of the poison and the route of intake.
Superficial uncomplicated wounds can be closed with tissue adhesive, whilst more complicated injuries will need surgical assessment and possibly exploration.

1.5.1 General treatment for ingestion 1.5.1.1 Gastrointestinal decontamination should be considered only for people who have self-harmed by poisoning who present early, are fully conscious with a protected airway, and are at risk of significant harm as a result of poisoning.
1.5.1.2 When a person who has self-poisoned presents to the emergency department within 1 hour of ingestion and is fully conscious and able to protect his or her own airway, emergency department staff should consider offering activated charcoal at the earliest opportunity.

Activated charcoal should be offered only when the substance(s) ingested are likely to be adsorbed by activated charcoal and when the person is considered to be at risk of significant harm.
1.5.1.3 When a person who has self-poisoned is fully conscious and able to protect his or her own airway, activated charcoal may also be considered between 1 and 2 hours after ingestion, as there is some evidence that activated charcoal may still be effective in reducing absorption, especially if the ingested substance delays gastric emptying, such as tricyclic antidepressants.
Activated charcoal should be offered only when the substance(s) ingested are likely to be adsorbed by activated charcoal and when the person is considered to be at risk of significant harm.

1.5.1.4 Multiple doses of activated charcoal should not be used in the management of self- poisoning to reduce absorption, or to promote elimination of poisons, unless specifically recommended by TOXBASE or following consultation with the National Poisons Information Service (NPIS).
1.5.1.5 Emetics, including ipecac (ipecacuanha), should not be used in the management of self-poisoning.

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Last modified July 2004 Page 19 of 52 Self-harm NICE clinical guideline 16 1.5.1.6 Cathartics as a specific treatment should not be used in the management of self- poisoning.

1.5.1.7 Gastric lavage should not be used in the management of self-poisoning unless specifically recommended by TOXBASE or following consultation with the NPIS.
1.5.1.8 Whole bowel irrigation should not be used in the management of self-poisoning, unless specifically recommended by TOXBASE or following consultation with the NPIS.

Collecting samples and interpreting results 1.5.1.9 Staff involved in the emergency treatment of self-poisoning should collect appropriate samples for analysis; usually this will be a sample of blood, although samples of urine, vomit or sometimes gastric contents may be indicated following discussion with the NPIS.
If possible, samples of the suspected poison should also be collected.

1.5.1.10 Hospital laboratory staff should provide emergency department staff with regular updates about which toxicology tests are available, both locally and at the nearest specialised toxicology laboratory.

These should include information on the correct methods of collecting, handling and storing samples, and how samples should be transferred to the laboratory.
1.5.1.11 Where emergency department staff are unsure about the value of undertaking a toxicology assay or about whether an assay is available locally, advice should be sought from TOXBASE, the local hospital laboratory, a specialised toxicology laboratory or the NPIS.

1.5.1.12 When emergency department staff are unsure about the interpretation of assay results, advice should be sought from the local hospital laboratory, specialised toxicology laboratory or the NPIS.
Information and laboratory services available to clinicians treating self-poisoning Emergency department staff should have easy access to TOXBASE, be fully trained in its use, and know how and when to contact the NPIS.

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Last modified July 2004 Page 20 of 52 Self-harm NICE clinical guideline 16 1.5.1.13 TOXBASE should be available to all clinical staff involved in the emergency treatment of self-poisoning.
TOXBASE should be the first point of call for poisons information.

1.5.1.14 The NPIS telephone number should be permanently and easily available to clinical staff involved in the emergency treatment of self-poisoning.

The NPIS should normally be contacted only directly after clinicians have accessed TOXBASE or if there is concern about the severity of poisoning in a particular case.
1.5.1.15 Clinical staff involved in the emergency treatment of self-poisoning should be given training to better understand human toxicology, in order to make best use of TOXBASE and the NPIS telephone service.

Emergency departments, in conjunction with local hospital laboratories or regional toxicology units, or NPIS units, should ensure all staff receive regular training.
1.5.1.16 In cases where the suspected poison is a substance for which little toxicology data exists, clinical and laboratory data about exposure and absorption should be passed to the NPIS to help in the development of TOXBASE and other poisons information databases.
1.5.1.17 For further information about the management of overdose with substances covered by this guideline and for the specific management and treatment of overdose with substances not covered in this guideline, clinicians should consult TOXBASE or discuss the individual case with the NPIS.

Paracetamol screening 1.5.1.18 Plasma paracetamol concentrations should be measured in all conscious patients with a history of paracetamol overdose, or suspected paracetamol overdose, as recommended by TOXBASE.
They should also be taken in patients with a presentation consistent with opioid poisoning, and in unconscious patients with a history of collapse where drug overdose is a possible diagnosis.

Plasma paracetamol levels should be measured for risk assessment no earlier than 4 hours and no later than 15 hours after ingestion, as results are not reliable outside this time period.

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Last modified July 2004 Page 21 of 52 Self-harm NICE clinical guideline 16 1.5.2 Management of paracetamol overdose 1.5.2.1 Following gut decontamination with activated charcoal as recommended in this guideline, TOXBASE should be used to guide the further management of paracetamol poisoning.

TOXBASE should be easily available to all clinicians treating paracetamol poisoning.
1.5.2.2 Intravenous acetylcysteine should be considered as the treatment of choice for paracetamol overdose (although the optimum dose is unknown).

If acetylcysteine is not available or cannot be used, for example in people who abuse intravenous drugs where intravenous access may be difficult, or for people with needle phobia, then TOXBASE should be consulted.
1.5.2.3 In the event of an anaphylactoid reaction following administration of intravenous acetylcysteine, procedures outlined in TOXBASE should be followed.

1.5.2.4 In cases of staggered ingestion of paracetamol, the procedures outlined in TOXBASE should be followed in conjunction with discussion with the NPIS.

1.5.3 Flumazenil in benzodiazepine overdose If poisoning with benzodiazepines is suspected, flumazenil, given cautiously, can help reduce the need for admission to intensive care.
Although widely used, flumazenil is not currently licensed for the treatment of benzodiazepine overdose in the UK.

1.5.3.1 When a positive diagnosis of self-poisoning with a benzodiazepine has been made, the possibility of mixed overdose should be considered, and investigated if necessary, at the earliest opportunity, especially if the patient's clinical progress suggests that he or she may later require admission to intensive care.
1.5.3.2 In patients who are unconscious or showing marked impairment of consciousness, with evidence of respiratory depression likely to lead to admission to intensive care with endotracheal intubation, and in whom self-poisoning with a benzodiazepine is suspected, flumazenil should be considered as a therapeutic option to avoid intubation and artificial ventilation.
The decision to administer flumazenil should be based upon a comprehensive assessment including a full clinical and biochemical assessment of the patient's respiratory status, and his or her ability to protect his or Copyright © NICE 2004.

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Last modified July 2004 Page 22 of 52 Self-harm NICE clinical guideline 16 her own airway.
Clinicians should, however, avoid the use of flumazenil in: patients who may have ingested proconvulsants, including tricyclic antidepressants; those who have a history of epilepsy; and patients who are dependent upon benzodiazepines.
1.5.3.3 When using flumazenil in the treatment of benzodiazepine poisoning, clinicians should use small doses, comparable to those used in other contexts, and administer slowly, to avoid the emergence of the more serious adverse reactions associated with the use of flumazenil.

1.5.3.4 Given the relatively high incidence of adverse psychological events experienced by patients following administration of flumazenil, the minimum effective dose should be used and only for as long as it is clinically necessary.
1.5.3.5 When using flumazenil in the treatment of benzodiazepine poisoning, care should be taken to ensure that patients who become agitated should be closely monitored and warned of the risk of re-sedation, especially if the patient expresses the desire to leave the treatment setting.

1.5.3.6 Flumazenil should be used in the treatment of benzodiazepine overdose only when full resuscitation equipment is immediately available.
1.5.3.7 Only clinicians who have been explicitly trained in the use of flumazenil for the treatment of benzodiazepine poisoning, as described in this guideline, should undertake to administer flumazenil in this context.

1.5.4 Treatment and management of poisoning with salicylates 1.5.4.1 Following gut decontamination with activated charcoal, where this is indicated by this guideline, the further treatment of self-poisoning with salicylates should follow the current guidance outlined in TOXBASE.
1.5.5 Treatment of opioid overdose 1.5.5.1 Naloxone should be used in the diagnosis and treatment of opioid overdose associated with impaired consciousness and/or respiratory depression.

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Last modified July 2004 Page 23 of 52 Self-harm NICE clinical guideline 16 1.5.5.2 The minimum effective dose of naloxone should be used to reverse respiratory depression caused by opioids without causing the patient to become agitated.
This is especially important in people who are dependent upon opioids.

1.5.5.3 When reversing the effects of opioids, especially long-acting opioids such as methadone, the use of an intravenous infusion of naloxone should be considered.

1.5.5.4 When reversing the effects of opioid overdose using naloxone in people who are dependent upon opioids, naloxone should be given slowly.

Preparations should be made to deal with possible withdrawal effects, especially agitation, aggression and violence.
1.5.5.5 When using naloxone in the treatment of opioid poisoning, regular monitoring of vital signs (including the monitoring of oxygen saturation) should be undertaken routinely until the patient is able to remain conscious with adequate spontaneous respiration unaided by the further administration of naloxone.
1.5.6 General treatment for self-injury The treatment of self-injury should be the same as for any other injury, although the level of distress should be taken into account, and therefore delays should be avoided.

Tissue adhesive is effective and simple to use for small superficial wounds.

1.5.6.1 In the treatment and management of injuries caused by self-cutting, appropriate physical treatments should be provided without unnecessary delay irrespective of the cause of the injury.
1.5.6.2 In the treatment and management of people with self-inflicted injuries, clinicians should take full account of the distress and emotional disturbance experienced by people who self-harm additional to the injury itself, in particular, immediately following injury and at presentation for treatment.
1.5.6.3 In the treatment and management of superficial uncomplicated injuries of greater than 5 cm in length, or deeper injuries of any length, wound assessment and exploration, in conjunction with a full discussion of preferences with the service user, should determine the appropriate physical treatment provided.

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Last modified July 2004 Page 24 of 52 Self-harm NICE clinical guideline 16 Superficial wound closure 1.5.6.4 In the treatment and management of superficial uncomplicated injuries of 5 cm or less in length, the use of tissue adhesive should be offered as a first-line treatment option.
1.5.6.5 In the treatment and management of superficial uncomplicated injuries of 5 cm or less in length, if the service user expresses a preference for the use of skin closure strips, this should be offered as an effective alternative to tissue adhesive.

1.6 Support and advice for people who repeatedly self-harm 1.6.1 Advice for people who repeatedly self-poison Service users who repeatedly self-poison, and their carers where appropriate, may need advice about the risks of self-poisoning.
1.6.1.1 Harm minimisation strategies should not be offered for people who have self-harmed by poisoning.

There are no safe limits in self-poisoning.

1.6.1.2 Where service users are likely to repeat self-poisoning, clinical staff (including pharmacists) may consider discussing the risks of self-poisoning with service users, and carers where appropriate.
1.6.2 Advice for people who repeatedly self-injure Advice regarding self-management of superficial injuries, harm minimisation techniques, alternative coping strategies and how best to deal with scarring should be considered for people who repeatedly self-injure.

1.6.2.1 For people presenting for treatment who have a history of self-harm, clinicians may consider offering advice and instructions for the self-management of superficial injuries, including the provision of tissue adhesive.
Discussion with a mental health worker may assist in the decision about which service users should be offered this treatment option.

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Last modified July 2004 Page 25 of 52 Self-harm NICE clinical guideline 16 1.6.2.2 Where service users are likely to repeat self-injury, clinical staff, service users and carers may wish to discuss harm minimisation issues/techniques.

Suitable material is available from many voluntary organisations.
1.6.2.3 Where service users are likely to repeat self-injury, clinical staff, service users and carers may wish to discuss appropriate alternative coping strategies.

Suitable material is available from many voluntary organisations.

1.6.2.4 Where service users have significant scarring from previous self-injury, consideration should be given to providing information about dealing with scar tissue.
1.7 Psychosocial assessment Everyone who has self-harmed should have a comprehensive assessment of needs and risk; engaging the service user is a prerequisite.

1.7.1 Engaging the service user 1.7.1.1 Healthcare workers should undertake the assessment of needs and risk for people who have self-harmed as part of a therapeutic process to understand and engage the service user.
1.7.2 Assessment of needs (specialist mental health professionals) 1.7.2.1 All people who have self-harmed should be offered an assessment of needs, which should be comprehensive and include evaluation of the social, psychological and motivational factors specific to the act of self-harm, current suicidal intent and hopelessness, as well as a full mental health and social needs assessment.

1.7.2.2 The comprehensive assessment of needs should be written clearly in the service user's notes.
1.7.2.3 To encourage joint clinical decision making, service users and the assessor should both read through the written assessment of needs, wherever possible, to mutually agree the assessment.

Agreement should be written into the service user's notes.

Where there is significant disagreement, the service user should be offered the opportunity to write his or her disagreement in the notes.

The assessment should be Copyright © NICE 2004.

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Last modified July 2004 Page 26 of 52 Self-harm NICE clinical guideline 16 passed on to their GP and to any relevant mental health services as soon as possible to enable follow-up.
1.7.3 Assessment of risk (specialist mental health professionals) 1.7.3.1 All people who have self-harmed should be assessed for risk; this assessment should include identification of the main clinical and demographic features known to be associated with risk of further self-harm and/or suicide, and identification of the key psychological characteristics associated with risk, in particular depression, hopelessness and continuing suicidal intent.
1.7.3.2 The assessment of risk should be written clearly in the service user's notes.

The assessment should also be passed on to their GP and to any relevant mental health services as soon as possible to enable follow-up.

1.7.3.3 See recommendations 1.3.11, 1.3.12 and 1.3.13 in 'Self-harm: longer-term management' (NICE clinical guideline 133).

1.7.3.4 See recommendations 1.3.11, 1.3.12 and 1.3.13 in 'Self-harm: longer-term management' (NICE clinical guideline 133).
1.7.3.5 Consideration should be given to combining the assessment of risks into a needs assessment framework to produce a single integrated psychosocial assessment process.

1.7.4 Training 1.7.4.1 All health professionals, including junior psychiatrists, social workers and psychiatric nurses, who undertake psychosocial assessment for people who have self-harmed should be properly trained and supervised to undertake assessment of needs and risk specifically for people who self-harm.
1.8 Referral, admission and discharge following self-harm Referral, treatment and discharge following self-harm should be based on the overall assessment of needs and risk.

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Last modified July 2004 Page 27 of 52 Self-harm NICE clinical guideline 16 1.8.1.1 The decision to refer for further assessment and/or treatment or to discharge the service user should be taken jointly by the service user and the healthcare professional whenever this is possible.
When this is not possible, either as a result of diminished mental capacity or the presence of significant mental illness, this should be explained to the service user and written in their notes.

1.8.1.2 Referral for further assessment and treatment should be based upon the combined assessment of needs and risk.

The assessment should be written in the case notes and passed onto the service user's GP and to any relevant mental health services as soon as possible to enable follow-up.
1.8.1.3 The decision to discharge a person without follow-up following an act of self-harm should be based upon the combined assessment of needs and risk.

The assessment should be written in the case notes and passed onto their GP and to any relevant mental health services.
1.8.1.4 In particular, the decision to discharge a person without follow-up following an act of self-harm should not be based solely upon the presence of low risk of repetition of self-harm or attempted suicide and the absence of a mental illness, because many such people may have a range of other social and personal problems that may later increase risk.

These problems may be amenable to therapeutic and/or social interventions.
1.8.1.5 Temporary admission, which may need to be overnight, should be considered following an act of self-harm, especially for people who are very distressed, for people in whom psychosocial assessment proves too difficult as a result of drug and/or alcohol intoxication, and for people who may be returning to an unsafe or potentially harmful environment.

Reassessment should be undertaken the following day or at the earliest opportunity thereafter.
1.9 Special issues for children and young people (under 16 years) Children and young people who self-harm have a number of special needs, given their vulnerability.

Physical treatments will follow similar principles as for adults.

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Last modified July 2004 Page 28 of 52 Self-harm NICE clinical guideline 16 1.9.1.1 Children and young people under 16 years of age who have self-harmed should be triaged, assessed and treated by appropriately trained children's nurses and doctors in a separate children's area of the emergency department.
1.9.1.2 Children's and young people's triage nurses should be trained in the assessment and early management of mental health problems and, in particular, in the assessment and early management of children and young people who have self-harmed.

1.9.1.3 All children or young people who have self-harmed should normally be admitted overnight to a paediatric ward and assessed fully the following day before discharge or further treatment and care is initiated.
Alternative placements may be required, depending upon the age of the child, circumstances of the child and their family, the time of presentation to services, child protection issues and the physical and mental health of the child; this might include a child or adolescent psychiatric inpatient unit where necessary.

1.9.1.4 For young people of 14 years and older who have self-harmed, admission to a ward for adolescents may be considered if this is available and preferred by the young person.
1.9.1.5 A paediatrician should normally have overall responsibility for the treatment and care of children and young people who have been admitted following an act of self-harm.

1.9.1.6 Following admission of a child or young person who has self-harmed, the admitting team should obtain parental (or other legally responsible adult) consent for mental health assessment of the child or young person.
1.9.1.7 Staff who have emergency contact with children and young people who have self- harmed should be adequately trained to assess mental capacity in children of different ages and to understand how issues of mental capacity and consent apply to this group.

They should also have access at all times to specialist advice about these issues.
1.9.1.8 In the assessment and treatment of self-harm in children and young people, special attention should be paid to the issues of confidentiality, the young person's consent Copyright © NICE 2004.

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Last modified July 2004 Page 29 of 52 Self-harm NICE clinical guideline 16 (including Gillick competence), parental consent, child protection, the use of the Mental Health Act in young people and the Children Act.
1.9.1.9 During admission to a paediatric ward following self-harm, the Child and Adolescent Mental Health Team should undertake assessment and provide consultation for the young person, his or her family, the paediatric team and social services and education staff as appropriate.

1.9.1.10 All children and young people who have self-harmed should be assessed by healthcare practitioners experienced in the assessment of children and adolescents who self-harm.
Assessment should follow the same principles as for adults who self- harm, but should also include a full assessment of the family, their social situation, and child protection issues.
1.9.1.11 Child and adolescent mental health service practitioners involved in the assessment and treatment of children and young people who have self-harmed should: be trained specifically to work with children and young people, and their families, after self-harm be skilled in the assessment of risk have regular supervision have access to consultation with senior colleagues.
1.9.1.12 Initial management should include advising carers of the need to remove all medications or other means of self-harm available to the child or young person who has self-harmed.

1.9.1.13 For the further management of young people who have self-harmed, see 'Self-harm: longer-term management' (NICE clinical guideline 133).
1.10 Special issues for older people (older than 65 years) When older people self-harm, treatments will be much the same as for younger adults, but the risk of further self-harm and suicide are substantially higher and must be taken into account.

1.10.1.1 All people older than 65 years of age who have self-harmed should be assessed by mental healthcare practitioners experienced in the assessment of older people who Copyright © NICE 2004.

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Last modified July 2004 Page 30 of 52 Self-harm NICE clinical guideline 16 self-harm.

Assessment should follow the same principles as for younger adults who self-harm, but should also pay particular attention to the potential presence of depression, cognitive impairment and physical ill health, and should include a full assessment of their social and home situation.
1.10.1.2 All acts of self-harm in people older than 65 years of age should be regarded as evidence of suicidal intent until proven otherwise because the number of people in this age range who go on to complete suicide is much higher than in younger adults.

1.10.1.3 Given the high risks amongst older adults who have self-harmed, consideration should be given to admission for mental health risk and needs assessment, and time given to monitor changes in mental state and levels of risk.
1.10.1.4 In all other respects, the assessment and treatment of older adults who have self- harmed should follow the recommendations given for adults.
1.11 Psychological, psychosocial and pharmacological interventions Referral for further assessment and/or treatment should be based upon a comprehensive psychosocial assessment, and should be aimed at treating a person's underlying problems or particular diagnosis rather than simply treating self-harming behaviour, although intensive therapeutic help with outreach may reduce the risk of repetition.

Whatever the treatment plan, primary care and mental health services should be informed.
1.11.1.1 Following psychosocial assessment for people who have self-harmed, the decision about referral for further treatment and help should be based upon a comprehensive psychiatric, psychological and social assessment, including an assessment of risk, and should not be determined solely on the basis of having self-harmed.
1.11.1.2 Clinicians should ensure that service users who have self-harmed are fully informed about all the service and treatment options available, including the likely benefits and disadvantages, in a spirit of collaboration, before treatments are offered.

The provision of relevant written material with time to talk over preferences should also be provided for all service users.

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Last modified July 2004 Page 31 of 52 Self-harm NICE clinical guideline 16 1.11.1.3 The mental health professional making the assessment should inform both mental health services (if they are involved already) and the service user's GP, in writing, of the treatment plan.

1.11.1.4 For the further management of people who have self-harmed, see 'Self-harm: longer- term management' (NICE clinical guideline 133).

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Last modified July 2004 Page 32 of 52 Self-harm NICE clinical guideline 16 2 Notes on the scope of the guidance All NICE guidelines are developed in accordance with a scope document that defines what the guideline will and will not cover.

The scope of this guideline was established at the start of the development of this guideline, following a period of consultation.
This guideline is relevant to people aged 8 years and older who have carried out acts of self- harm, regardless of whether accompanied by mental illness, and to all healthcare professionals involved in the help, treatment and care of people who self-harm, and their carers.

The guideline makes recommendations that cover the first 48 hours following an act of self-harm, but does not address the longer-term psychiatric care of people who self-harm.
The professional groups that this guideline will be relevant to include the following.

Professional groups who are involved in the care and treatment of people who have self- harmed, including emergency department staff, paramedical and ambulance staff, general practitioners, counsellors, paediatricians, paediatric nurses, psychiatrists, prison health staff, clinical psychologists, mental health nurses, community psychiatric nurses, social workers, practice nurses and others.
Professionals in other health and non-health sectors who may have direct contact with, or are involved in the provision of health and other public services for, people who have self- harmed.

These may include occupational therapists, art therapists, pharmacists, and the police and professionals who work in the criminal justice and education sectors.
Those with responsibility for planning services for people who self-harm and their carers, including directors of public health, NHS trust managers and managers in primary care trusts.

The guideline will cover the acute care of self-harm in people with learning disabilities, but not repetitive self-injurious behaviour, such as head banging.

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Last modified July 2004 Page 33 of 52 Self-harm NICE clinical guideline 16 3 Implementation in the NHS 3.1 In general The implementation of this guideline will build on the National Service Framework for Mental Health in England and Wales and should form part of the service development plans for each local health community in England and Wales.
Local health communities should review their existing practice for self-harm against this guideline as they develop their Local Delivery Plans.

The review should consider the resources required to implement the recommendations set out in Section 1, the people and processes involved and the timeline over which full implementation is envisaged.

It is in the interests of service users that the implementation timeline is as rapid as possible.
Relevant local clinical guidelines, care pathways and protocols should be reviewed in the light of this guidance and revised accordingly.

This guideline should be used in conjunction with the National Service Framework for Mental Health.

3.2 Audit Suggested audit criteria are listed in Appendix D. These can be used as the basis for local clinical audit, at the discretion of those in practice.

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Last modified July 2004 Page 34 of 52 Self-harm NICE clinical guideline 16 4 Research recommendations The following research recommendations have been identified for this NICE guideline, not as the most important research recommendations, but as those that are most representative of the full range of recommendations.
The Guideline Development Group's full set of research recommendations is detailed in the full guideline produced by the National Collaborating Centre for Mental Health (see Section 5).

Research, using appropriate survey and rigorous qualitative methods, should be conducted about the meaning of self-harm to people from different ethnic and cultural groups.

This should include the exploration of issues of intentionality.
A study using an appropriate and rigorously applied qualitative methodology should be undertaken to explore user experiences of services.

Qualitative research methods, such as Q sort and Interpretive Phenomenological Analysis, should be used to better understand staff attitudes to self-harm and their psychological and social origins.
A study of appropriate design reporting all relevant patient outcomes (mortality, morbidity, numbers lost to the service, patient satisfaction) should be undertaken to assess the impact of the introduction of the Mental Health Triage Scale.

Further research into treatments specific to people who self-harm should evaluate the differential responses of different patient subgroups, using a broad range of outcomes, especially those relevant to service users, such as quality of life.
An adequately powered RCT reporting all relevant outcomes should be undertaken to determine the clinical and cost effectiveness of intensive interventions combined with assertive outreach for people who self-harm.

The study should address patient characteristics (such as age, gender, diagnosis, frequency and method of self-harm, past history of abuse) and therapists' characteristics (such as age, gender, training, professional discipline, parental status).
Outcomes should include loss from services, admission rates, satisfaction, repetition of self-harm, quality of life, and employment status.

An appropriately designed and adequately powered study should be undertaken to clarify the optimum dose level at which acetylcysteine should be used (for both oral and intravenous administration) in the treatment of paracetamol poisoning, reporting all relevant biochemical and clinical outcomes, including liver function, liver failure and Copyright © NICE 2004.
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Last modified July 2004 Page 35 of 52 Self-harm NICE clinical guideline 16 adverse reactions.

Consideration should be given to patient characteristics such as co- ingested substances, including alcohol.

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Last modified July 2004 Page 36 of 52 Self-harm NICE clinical guideline 16 5 Other versions of this guideline Full guideline The National Institute for Clinical Excellence commissioned the development of this guidance from the National Collaborating Centre for Mental Health.

The Centre established a Guideline Development Group, which reviewed the evidence and developed the recommendations.
The full guideline Self-harm: the short-term physical and psychological management and secondary prevention of self-harm in primary and secondary care will be published by the National Collaborating Centre for Mental Health; it will be available from its website, the NICE website, and on the website of the National Electronic Library for Health.

The members of the Guideline Development Group are listed in Appendix B.
Information about the independent Guideline Review Panel is given in Appendix C. The booklet The Guideline Development Process – An Overview for Stakeholders, the Public and the NHS has more information about the Institute's guideline development process.

It is available from the Institute's website and copies can also be ordered by telephoning 0870 1555 455 (quote reference N0472).
Information for the public A version of this guideline for people who self-harm, their advocates and carers, and for the public (including information for children and young people) is available from the NICE website (www.nice.org.uk/CG016publicinfo) or from the NHS Response Line (0870 1555 455; quote reference number N0626 for an English version and N0627 for an English and Welsh version).

This is a good starting point for explaining to patients the kind of care they can expect.
Quick reference guide A quick reference guide for healthcare professionals is also available from the NICE website or from NICE publications (0845 033 7783; quote reference number N0625).

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Last modified July 2004 Page 37 of 52 Self-harm NICE clinical guideline 16 6 Review date The process of reviewing the evidence is expected to begin 4 years after the date of issue of this guideline.
Reviewing may begin earlier than 4 years if significant evidence that affects the guideline recommendations is identified sooner.

The updated guideline will be available within 2 years of the start of the review process.

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Last modified July 2004 Page 38 of 52 Self-harm NICE clinical guideline 16 Appendix A: Grading scheme All evidence was classified according to an accepted hierarchy of evidence that was originally adapted from the US Agency for Healthcare Policy and Research Classification (see Box 1).
Recommendations were then graded A to C on the basis of the level of associated evidence or noted as a GPP recommendation (see Box 1) – this grading scheme is based on a scheme formulated by the Clinical Outcomes Group of the NHS Executive (1996).
Box 1: Hierarchy of evidence and recommendations grading scheme Level Type of evidence Grade Evidence I Evidence obtained from a A At least one randomised controlled trial as single randomised controlled part of a body of literature of overall good trial or a meta-analysis of quality and consistency addressing the randomised controlled trials specific recommendation (evidence level I) without extrapolation IIa Evidence obtained from at B Well-conducted clinical studies but no least one well-designed randomised clinical trials on the topic of controlled study without recommendation (evidence levels II or III); or randomisation extrapolated from level I evidence IIb Evidence obtained from at least one other well-designed quasi-experimental study III Evidence obtained from well- designed non-experimental descriptive studies, such as comparative studies, correlation studies IV Evidence obtained from C Expert committee reports or opinions and/or expert committee reports or clinical experiences of respected authorities Copyright © NICE 2004.
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Last modified July 2004 Page 39 of 52 Self-harm NICE clinical guideline 16 opinions and/or clinical (evidence level IV).

This grading indicates experiences of respected that directly applicable clinical studies of authorities good quality are absent or not readily available GPP Recommended good practice based on the clinical experience of the Guideline Development Group Adapted from Eccles, M and Mason, J (2001).

How to develop cost-conscious guidelines.


Health Technology Assessment 5: 16; NHS Executive.

Clinical Guidelines: Using Clinical Guidelines to Improve Patient Care Within the NHS.

London: 1996 Copyright © NICE 2004.

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Last modified July 2004 Page 40 of 52 Self-harm NICE clinical guideline 16 Appendix B: The Guideline Development Group Professor Paul Lelliott (Chair) Director, College Research Unit, Royal College of Psychiatrists Consultant Psychiatrist, Oxleas Mental Heath NHS Trust Dr Tim Kendall (Facilitator) Co-Director, National Collaborative Centre for Mental Health Deputy Director, Royal College of Psychiatrists Research Unit Medical Director and Consultant Psychiatrist, Sheffield Care Trust Mr Simon Armson Chief Executive, Samaritans (until July 2004) Psychotherapist and Mental Health Act Commissioner Mr Simon Baston Charge Nurse, Emergency Nurse Practitioner, A&E Department, Sheffield Teaching Hospitals Ms Pamela Blackwood Social Worker and Mental Health Locality Manager, Greenwich Social Services (until May 2003) Caller Services Manager, Samaritans Lead, Topic Group on User Experience Rachel Burbeck Lead Systematic Reviewer Michelle Clark Project Manager (until November 2002) Professor Allan House Academic Unit and Behavioural Sciences, University of Leeds Lead, Topic Group on Psychosocial Issues and Interventions Mr Keith Jackson Paramedic & Staff Officer, London Ambulance Service NHS Trust Copyright © NICE 2004.
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Last modified July 2004 Page 41 of 52 Self-harm NICE clinical guideline 16 Richard Jenkins Systematic Reviewer Dr Marcia Kelson Director, Patient Involvement Unit for NICE Rebecca King Project Manager (from November 2002) Dr Huw Lloyd General Practitioner and Chair of Mental Health Group, Royal College of General Practitioners Mr Richard Pacitti Carer and Chief Executive, Mind in Croydon Mr Carlos Perez-Avila Consultant in Emergency Medicine, Royal Sussex County Hospital, Brighton Preethi Premkumar Research Assistant Dr Clare Taylor Editor Dr Glyn Volans Physician and Director, Medical Toxicology Unit, Guy's and St Thomas Hospital NHS Trust (until November 2003).
Lead, Topic Group on Medical and Surgical Treatments Heather Wilder Information Scientist Miss Heather Wiseman Clinical Scientist, Medical Toxicology Unit, Guy's and St Thomas Hospital NHS Trust Copyright © NICE 2004.

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Last modified July 2004 Page 42 of 52 Self-harm NICE clinical guideline 16 Appendix C: The Guideline Review Panel The Guideline Review Panel is an independent panel that oversees the development of the guideline and takes responsibility for monitoring its quality.
The Panel includes experts on guideline methodology, health professionals and people with experience of the issues affecting patients and carers.

The members of the Guideline Review Panel were as follows.
Dr Chaand Nagpaul (Chair) General practitioner, Stanmore Mr John Seddon Patient representative Professor Kenneth Wilson Professor of Psychiatry of Old Age and Honorary Consultant Psychiatrist, Cheshire and Wirral Partnership NHS Trust Professor Shirley Reynolds Professor of Clinical Psychology, School of Medicine, Health Policy and Practice, University of East Anglia, Norwich Dr Roger Paxton R&D Director, Newcastle, North Tyneside and Northumberland Mental Health NHS Trust Copyright © NICE 2004.
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Last modified July 2004 Page 43 of 52 Self-harm NICE clinical guideline 16 Appendix D: Technical detail on the criteria for audit Objectives for the audit One or more audits can be carried out in different care settings to ensure that: individuals who self-harm are involved in their care treatment options are appropriately offered and provided for individuals who self-harm.

Individuals to be included in an audit A single audit could include all individuals who self-harm.
Alternatively, individual audits could be undertaken on specific groups of individuals such as: people who self-poison or self-injure a sample of people from particular populations in primary care.

Measures that could be used as a basis for an audit See following table.

Standards Criteria Audit methods 1.
Staff show respect 1.1 People who self-harm and Survey of a consecutive and understanding to present to an emergency series of people attending an people who self-harm department report that they: emergency department after and present to an emergency department self-harm are treated respectfully are given full information about their treatment and care are fully involved in decisions about their treatment and care are provided with written information about relevant local services Copyright © NICE 2004.
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Last modified July 2004 Page 44 of 52 Self-harm NICE clinical guideline 16 2.

Trusts provide 2.1 Training includes: A.

Review of trusts' training appropriate training for healthcare staff who have contact with people who self-harm the problems faced by people records who self-harm when they B.
Survey staff perceptions of have contact with services the quality of training an exploration of some of the meanings of and motives for self-harm capacity and consent in relation to self-harm assessment of people who self-harm early management, including the use of activated charcoal the content of the NICE guideline 3.
Activated charcoal 3.1 Ambulance crews give Review of Ambulance should be immediately activated charcoal at the earliest staff/emergency department available to ambulance opportunity and within 1 hour records of consecutive series and emergency following ingestion to a person who of patients assessed by department staff has self-poisoned ambulance/emergency involved in the care of people who have self- harmed by poisoning at all times department staff 3.2 Emergency department staff give activated charcoal at the earliest opportunity and within 1 hour following ingestion to a person who has self-poisoned (unless administered previously) 3.3 Emergency department staff give activated charcoal between 1 and 2 hours of ingestion to people who have self-poisoned and are at Copyright © NICE 2004.
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Last modified July 2004 Page 45 of 52 Self-harm NICE clinical guideline 16 risk of significant harm 4.
Healthcare staff who 4.1 Ambulance staff who attend a Review of written ambulance have first contact with person who has self-harmed staff/triage nurse assessments of consecutive series of patients who attend emergency department having self-harmed people who self-harm record: conduct an adequate initial assessment information about home environment social and family support network history leading to self-harm patient's emotional state and level of distress 4.2 Ambulance staff collect all substances and medications found at the scene 4.3 The triage assessment in the emergency department includes: capacity and willingness to stay and accept treatment needs for physical care need for urgent psychosocial and/or psychiatric assessment (the use of a standardised mental health triage system such as the Australian Mental Health Triage Scale would fulfil this criterion) 4.4 The triage assessment takes account of information provided by the ambulance staff if they were Copyright © NICE 2004.
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Last modified July 2004 Page 46 of 52 Self-harm NICE clinical guideline 16 involved in conveying the person to hospital 5.

Emergency 5.1 Emergency departments offer Survey of a consecutive departments have people who have self-harmed the series of people attending an appropriate facilities for option of waiting for treatment in an emergency department after the care of people who environment that is safe, supportive self-harm have self-harmed and that minimises distress.
This must include regular contact with a named member of staff 6.

Healthcare staff offer 6.1 Physical treatment includes: Survey of a consecutive treatment for the physical consequences of self-harm, regardless of the patient's willingness to accept psychosocial assessment or psychiatric treatment wound assessment adequate anaesthesia and/or analgesia, to be reassessed throughout treatment tissue adhesive sedation series of people attending an emergency department after self-injury 7.
Healthcare 7.1 Healthcare staff who attend a Survey of a consecutive professionals offer full person who has self-harmed make series of people attending an information about the all efforts necessary to ensure that emergency department after treatment options someone who has self-harmed can self-harm give, and has the opportunity to give, meaningful and informed consent before any and each procedure or treatment is initiated 8.
A healthcare 8.1 The needs assessment Review of emergency professional conducts includes: and records a comprehensive social situation (living arrangements, work, debt) departments/mental health records of consecutive series of patients assessed Copyright © NICE 2004.

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Last modified July 2004 Page 47 of 52 Self-harm NICE clinical guideline 16 assessment of personal relationships following an episode of self- psychosocial needs for recent life events and current harm every person who self- difficulties harms and presents to psychiatric history (including the health service previous self-harm, drug/alcohol use) mental state examination enduring psychological characteristics associated with self-harm motivation for the act 8.2 Decision about referral for further management should be based upon a combined needs and risk assessment 9.
A healthcare 9.1 The risk assessment includes: Review of emergency professional conducts and records a comprehensive assessment of risk for every person who self- harms and presents to the health service characteristics of the act of self-harm (intent, medical seriousness, use of violent methods, evidence of department/mental health records of consecutive series of patients assessed following an episode of self- planning, precautions taken to harm prevent rescue) characteristics of the person (hopelessness, forensic history, future suicidal intent) circumstances of the person (social class, physical illness, recent bereavement, social isolation) Copyright © NICE 2004.
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Last modified July 2004 Page 48 of 52 Self-harm NICE clinical guideline 16 Clinicians should review the findings of measurement, identify whether practice can be improved, agree on a plan to achieve any desired improvement and repeat the measurement of actual practice to confirm that the desired improvement is being achieved.

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Last modified July 2004 Page 49 of 52 Self-harm NICE clinical guideline 16 About this guideline NICE clinical guidelines are recommendations about the treatment and care of people with specific diseases and conditions in the NHS in England and Wales.

The guideline was developed by the National Collaborating Centre for Mental Health, which is based at the Royal College of Psychiatrists.
The Collaborating Centre worked with a group of healthcare professionals (including consultants, GPs and nurses), patients and carers, and technical staff, who reviewed the evidence and drafted the recommendations.

The recommendations were finalised after public consultation.

The methods and processes for developing NICE clinical guidelines are described in The guidelines manual.

The recommendations from this guideline have been incorporated into a NICE Pathway.
We have produced a summary for patients and carers.

Tools to help you put the guideline into practice and information about the evidence it is based on are also available.

Your responsibility This guidance represents the view of NICE, which was arrived at after careful consideration of the evidence available.

Healthcare professionals are expected to take it fully into account when exercising their clinical judgement.
However, the guidance does not override the individual responsibility of healthcare professionals to make decisions appropriate to the circumstances of the individual patient, in consultation with the patient and/or guardian or carer, and informed by the summary of product characteristics of any drugs they are considering.

Implementation of this guidance is the responsibility of local commissioners and/or providers.
Commissioners and providers are reminded that it is their responsibility to implement the guidance, in their local context, in light of their duties to avoid unlawful discrimination and to have regard to promoting equality of opportunity.

Nothing in this guidance should be interpreted in a way that would be inconsistent with compliance with those duties.

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Last modified July 2004 Page 50 of 52 Self-harm NICE clinical guideline 16 © National Institute for Health and Clinical Excellence 2004.

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No reproduction by or for commercial organisations, or for commercial purposes, is allowed without the written permission of NICE.
Contact NICE National Institute for Health and Clinical Excellence Level 1A, City Tower, Piccadilly Plaza, Manchester M1 4BT www.nice.org.uk nice@nice.org.uk 0845 033 7780 Copyright © NICE 2004.

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Last modified July 2004 Page 51 of 52 Self-harm NICE clinical guideline 16 Changes since publication In November 2011 the following recommendations were replaced with recommendations from Self-harm: longer-term management (NICE clinical guideline CG133): recommendations 1.7.3.3 and 1.7.3.4 on assessment of risk, 1.9.1.13 on special issues for children and young people, and 1.11.1.4 on psychological, psychosocial and pharmacological interventions.
Recommendation 1.11.1.5 on psychological, psychosocial and pharmacological interventions has been withdrawn.

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